Mary Sharp, age 46, is admitted to your neuroscience unit 1 day after an anterior cervical fusion. The three-level fusion required nearly 4 hours. During report, you’re told that the patient experienced nausea and vomiting last night and that an antiemetic relieved them.
Assessment hints
During your initial assessment, you note no obvious distress. When you remove the anterior portion of the hard cervical collar, you see that the dressing is dry and intact, but the tissue has more bruising and swelling than you expect. Ms. Sharp’s trachea is midline, and her breathing isn’t labored. Capillary refill is brisk, and her oxygen saturation is 99% on room air. Her arm motor strength and sensation are intact.
About 45 minutes later, the patient experiences nausea and vomiting again. You give her an antiemetic and call the physician to report the neck swelling. An hour later, you assess her neck again and note no change. The nausea has subsided, and the patient says she’s comfortable.
Two hours later, she has difficulty swallowing when she tries her liquid diet. Her trachea is still midline, but the neck swelling has increased. When you report this change, the physician orders dexamethasone (Decadron) to reduce the swelling.
Call for help
Less than 90 minutes later, the patient has difficulty managing her secretions. You note that the swelling and bruising now extend to the clavicle and the trachea is deviated. Because of the speed of the changes, you suspect a hematoma at the surgical site is pressing on the trachea and esophagus. Given the imminent threat of an airway obstruction, you page the rapid response team (RRT), request an oxygen set-up and code cart from the charge nurse, and tell the unit secretary to page the physician immediately. To ease the patient’s anxiety, you stay with her.
On the scene
Just as the RRT arrives, the physician answers your page. You explain your concern about the patient’s airway. The physician concurs and orders the patient be sent directly to the operating room for surgical evacuation of the hematoma.
Outcome
Thanks to your thorough assessments and prompt actions, the hematoma is quickly evacuated, and Ms. Sharp’s airway doesn’t become obstructed. Two days later, she’s discharged with no deficits.
Education and follow-up
Before her discharge, you explain that the postoperative period for anterior cervical fusion surgery is usually uneventful, but that certain factors—an operating-room time of 220 minutes or more; surgery on three or more cervical levels that include C2, C3, or C4; an estimated blood loss of 300 mL or more; and a patient age of 55 or more—increase the risk of airway complications. Ms. Sharp’s extended operating-room time and three-level fusion that included C4 placed her at increased risk. You also explain that the repeated vomiting may have contributed to her airway complication.
Ms. Sharp was lucky. She could have suffered a devastating hypoxic brain injury, or she could have died. Fortunately, she had a nurse who knows the importance of thorough, postoperative neck assessments and critical-thinking skills.
Susan Tocco, MSN, RN, CNRN, CCNS, is a Neuroscience Clinical Nurse Specialist at Orlando Regional Medical Center in Florida.
